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Epidemiology and Infection Charting elimination in the pandemic: a SARS-CoV-2 serosurvey of blood donors in cambridge.org/hyg New Zealand

1 1 1 1 Short Paper Lauren H. Carlton , Tiffany Chen , Alana L. Whitcombe , Reuben McGregor , Greg Scheurich2, Campbell R. Sheen3, James M. Dickson4, Chris Bullen5, Cite this article: Carlton LH et al (2021). 5 5 5 6 Charting elimination in the pandemic: a Annie Chiang , Daniel J. Exeter , Janine Paynter , Michael G. Baker , SARS-CoV-2 serosurvey of blood donors in New 2 1 Zealand. Epidemiology and Infection 149, e173, Richard Charlewood and Nicole J. Moreland 1–4. https://doi.org/10.1017/ S0950268821001643 1School of Medical Sciences, The University of Auckland, Auckland, New Zealand; 2The New Zealand Blood Service, Auckland, New Zealand; 3Callaghan Innovation, Christchurch, New Zealand; 4School of Biological Received: 7 May 2021 Sciences, The University of Auckland, Auckland, New Zealand; 5School of Population Health, The University of Revised: 7 July 2021 Auckland, Auckland, New Zealand and 6Department of Public Health, University of Otago, Wellington, New Accepted: 8 July 2021 Zealand Key words: COVID-19; elimination; New Zealand; receptor Abstract binding domain; SARS-CoV-2; seroprevalence; serosurvey; Spike New Zealand has a strategy of eliminating SARS-CoV-2 that has resulted in a low incidence of reported coronavirus-19 disease (COVID-19). The aim of this study was to describe the Author for correspondence: spread of SARS-CoV-2 in New Zealand via a nationwide serosurvey of blood donors. Nicole J. Moreland, Samples (n = 9806) were collected over a month-long period (3 December 2020–6 January E-mail: [email protected] 2021) from donors aged 16–88 years. The sample population was geographically spread, cov- ering 16 of 20 district health board regions. A series of Spike-based immunoassays were utilised, and the serological testing algorithm was optimised for specificity given New Zealand is a low prevalence setting. Eighteen samples were seropositive for SARS-CoV-2 antibodies, six of which were retrospectively matched to previously confirmed COVID-19 cases. A further four were from donors that travelled to settings with a high risk of SARS-CoV-2 exposure, suggesting likely infection outside New Zealand. The remaining eight seropositive samples were from seven different district health regions for a true seroprevalence estimate, adjusted for test sensitivity and specificity, of 0.103% (95% confidence interval, 0.09–0.12%). The very low seroprevalence is consistent with limited undetected community transmission and provides robust, serological evidence to support New Zealand’s successful elimination strategy for COVID-19.

New Zealand has a strategy of eliminating SARS-CoV-2 that has resulted in a low incidence of coronavirus-19 disease (COVID-19). The first case was reported on 26 February 2020, and the country entered a strict nationwide lockdown one month later for 49 days [1]. Through rigor- ous border control and managed isolation and quarantine facilities for new arrivals, New Zealand has since remained largely COVID-19 free. Globally, serological surveillance has been utilised throughout the pandemic to define the cumulative incidence, including estima- tions of missed cases and/or asymptomatic infection. Due to lockdowns and movement restric- tions, blood donors have been used as a sentinel population in many settings [2, 3]. The aim of this study was to describe the spread of SARS-CoV-2 in New Zealand via a blood donor serosurvey. Though the pandemic response has been highly effective, PCR testing was initially restricted due to limited diagnostic reagents [4] and there have been occasional border incur- sions and small community outbreaks, including a cluster in August 2020 with no identified link to the border. Samples were collected by the New Zealand Blood Service via nine static collection centres and 36 mobile collection services over a 4-week period (3 December 2020–6 January 2021) © The Author(s), 2021. Published by from individuals aged 16–88 years. Duplicates were removed, leaving 9806 samples for ana- Cambridge University Press. This is an Open lysis. Compared with the 2018 New Zealand census, participants were more likely to be Access article, distributed under the terms of aged 40–59 years (43.3% vs. 25.9%) and of European ethnicity (77.8% vs. 61.0%) but had a the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), similar proportion of females (49.1% vs. 50.7%) and were geographically spread with 16 of which permits unrestricted re-use, distribution 20 district health board regions represented (Table 1 and Supplementary Appendix). This and reproduction, provided the original article study was assessed by the Health and Disability Ethics Committee, and additional consent is properly cited. was not required (21/CEN/21). Antibodies to the Spike (S) protein and receptor-binding domain (RBD) persist for many months after infection, compared with antibodies to the nucleocapsid (N) protein [5, 6], pro- viding a rationale for the use of S protein-based assays in serosurveys. The overall serological testing algorithm was optimised for specificity given the low number of reported COVID-19

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Table 1. Demographics of the blood donors, 2018 Census population and COVID-19 cases in New Zealand

Blood donors 2018 Census population COVID-19 cases

n % n % n %

Total 9806 100.00 4 793 361 100.00 2190 100.00 Sex Male 4990 50.89 2 364 315 49.30 1037 47.35 Female 4816 49.11 2 429 046 50.70 1153 52.65 Prioritised ethnicity Māori 710 7.24 777 195 16.20 192 8.77 Pacific Island 192 1.96 314 202 6.60 184 8.40 Asian 921 9.39 705 384 14.70 393 17.95 MELAA 144 1.47 68 283 1.40 73 3.33 European/othera 7631 77.82 2 924 175 61.00 1337 61.05 Unknown 208 2.12 4122 0.10 11 0.50 Age 0–14 years 0 0.00 927 102 19.34 177 8.08 15–19 yearsb 238 2.43 308 304 6.40 110 5.02 20–29 years 1754 17.89 681 963 14.20 520 23.76 30–39 years 1870 19.07 624 363 13.00 398 18.14 40–49 years 2053 20.94 619 641 12.90 309 14.12 50–59 years 2196 22.39 623 445 13.00 320 14.62 60–69 years 1437 14.65 510 327 10.60 222 10.14 70+ years 258 2.63 498 216 10.40 134 6.12 District Health Board (DHB) Northland 200 2.04 179 007 3.70 28 1.28 Auckland 1478 15.07 467 595 9.80 226 10.32 Waitemata 613 6.25 586 329 12.20 297 13.57 Counties Manukau 494 5.04 537 633 11.20 217 9.91 Waikato 1096 11.18 405 555 8.50 194 8.86 Taranaki 285 2.91 117 684 2.50 16 0.73 Lakes 282 2.88 109 080 2.30 16 0.73 Bay of Plenty 550 5.61 240 117 5.00 48 2.19 Tairawhiti 0 0.00 47 520 1.00 4 0.18 Hawkes Bay 51 0.52 166 287 3.50 44 2.01 Mid central 792 8.08 174 993 3.70 32 1.46 Whanganui 0 0.00 64 599 1.30 9 0.41 Wairarapa 51 0.52 45 327 0.90 8 0.37 Hutt Valley 214 2.18 148 509 3.10 24 1.10 Capital and Coast 1082 11.03 303 957 6.30 96 4.39 Nelson Marlborough 0 0.00 150 528 3.10 49 2.24 West Coast 0 0.00 31 578 0.70 5 0.23 Canterbury 1774 18.09 539 628 11.30 168 7.67 South Canterbury 113 1.15 58 977 1.20 17 0.78 Southern 731 7.45 324 387 6.80 216 9.87 (Continued)

Table 1. (Continued.)

Blood donors 2018 Census population COVID-19 cases

n % n % n %

Unknown 0 0.00 94 071 2.00 0 0.00 Managed Isolation and Quarantine (MIQ) – 0 0.00 0 0.00 476 21.70

MELAA, Middle Eastern, Latin American and African. The New Zealand blood service donations were collected between the 3rdof December 2020 and the 6thof January 2021. Of the 9806individuals, 9771are blood donors and 35are livingtissue and stem celldonors. Alldonors must befree of illness and weigh>50 kg. Notabletravel anda historySARS-CoV-2 infection (orcontact with a positive case) are recordedpriorto collection.The healthboardregion provided for the donors is based on donation location. Demographics for COVID-19 cases were obtained from the New Zealand Ministry of Health and include probable and confirmed infections up to and including the 6th of January 2021. The most recent New Zealand census took place in March 2018. Priority ethnicity is reported as defined by the New Zealand Department of Statistics. a‘Other’ comprises of n = 28 (0.20%) of the blood donor population, and n = 51 447 (1.10%) of the New Zealand census population. bAll blood donors are at least 16 years of age.

Fig. 1. Antibody characteristics of the seropositive donors (n = 18). (a) Seropositivity was confirmed by EuroImmun S1 IgG (top) and the surrogate Viral Neutralisation Test (sVNT, bottom). Six donors had PCR-confirmed SARS-CoV-2 infection (dark grey), four had relevant travel history (dark turquoise) and eight were identified in this study (orange). The manufacturer cut-offs are shown (black dotted line). (b) Pearson correlation of sVNT and the Euroimmun IgG ELISA (n = 18). (c) Rose plot showing the percentage of seropositive donors over baseline for IgG, IgA and IgM antibodies against the RBD, Spike (S) and nucleocapsid (N) proteins determined using a multi-plex Luminex bead assay.

cases in New Zealand (2190 as of 6 January 2021) and the asso- and the cPass surrogate Viral Neutralisation Test (sVNT) ciated period prevalence of 0.04%, which limits the positive pre- (GenScript, New Jersey, USA) and the values deemed seropositive dictive value of tests with reduced specificity [7]. Samples were if above the cut-off on both commercial assays. Sensitivity and first screened with a widely used and well-validated two-step specificity for these assays were determined by Receiver ELISA that comprises a single point dilution assay against the Operator Characteristic (ROC) curves based on previous analyses RBD followed by titration against trimeric S protein (413 pre-pandemic negatives, 99 PCR confirmed cases) (Supplementary Appendix) [8, 9]. Samples above the cut-off (Supplementary Appendix) [9, 10]. were tested on two further immunoassays – the EuroImmun Of the 9806 samples, 18 were positive for both Spike IgG SARS-CoV-2 IgG ELISA (EuroImmun AG, Lübeck, Germany) (EuroImmun) and antibodies that block the RBD-hACE-2

interaction (sVNT), with the values highly correlated (Pearson r Data. Data, in addition to those available in the Supplementary information, 0.7993, P < 0.0001) (Fig. 1). Further analysis of the 18 seropositive are available from the authors on request. samples with a multiplex bead-based assay that detects antibody Acknowledgements. This work was funded by the School of Medicine isotype reactivity to RBD, S and N proteins [5] revealed a pattern Foundation (University of Auckland), and the COVID-19 Innovation consistent with infections that occurred weeks or months prior; a Acceleration Fund (Ministry of Business, Innovation and Employment). The dominance of RBD and S protein IgG with few samples positive 2018 Census data used in this study were supplied by Statistics New for N protein IgG, nor IgA or IgM against any of the three anti- Zealand (Stats NZ) and accessed via its Integrated Data Infrastructure (IDI). gens (Fig. 1). Within these 18 seropositive samples, six were retrospectively matched to donors with previously confirmed Statistics New Zealand Disclaimer. Access to the data used in this study SARS-CoV-2 infections. That all confirmed cases were detected was provided by Stats NZ under conditions designed to give effect to the secur- supports the rationale of the testing algorithm applied. A further ity and confidentiality provisions of the Statistics Act 1975. The results pre- sented in this study are the work of the author, not Stats NZ or individual four seropositive samples were from donors with 2020 travel his- data suppliers. tory in settings with a high risk of SARS-CoV-2 exposure (UK and Europe), suggesting likely infection outside New Zealand. The remaining eight seropositive samples were from seven different district health regions, giving a crude seroprevalence estimate References – of 0.082% (95% confidence intervals (CI) 0.035 0.16%). Applying 1. 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